Peritoneal Flap Following Lymph Node Dissection in Robotic Radical Prostatectomy: A Novel “Bunching” Technique

Background: Pelvic lymph node dissection (PLND) is recommended while performing robot-assisted radical prostatectomy (RARP) for patients with localized intermediate or high-risk prostate cancer. However, symptomatic lymphoceles can occur after surgery, adding significant morbidity to patients. Our objective is to describe a novel Peritoneal Bladder Flap Bunching technique (PBFB) to reduce the risk of clinically significant lymphoceles in patients undergoing RARP and PLND. Methods: We evaluated 2267 patients who underwent RARP with PLND, dividing them into two groups: Group 1, comprising 567 patients who had the peritoneal flap (PBFB), and Group 2, comprising 1700 patients without the flap; propensity score matching carried out at a 1:3 ratio. Variables analyzed included estimated blood loss (EBL), operative time, postoperative complications, lymphocele formation, and the development of symptomatic lymphocele. Results: The two groups exhibited similar preoperative characteristics after matching. There was no statistically significant difference in the occurrence of lymphoceles between the flap group and the non-flap group, with rates of 24% and 20.9%, respectively (p = 0.14). However, none of the patients in the flap group (0%) developed symptomatic lymphoceles, whereas 2.2% of patients in the non-flap group experienced symptomatic lymphoceles (p = 0.01). Conclusion: We have demonstrated a modified technique for a peritoneal flap (PBFB) with the initial elimination of postoperative symptomatic lymphoceles and promising short-term outcomes

Implementation and outcomes of HugoTM RAS System in robotic-assisted radical prostatectomy.

BACKGROUND: The results and benefits of Robotic-assisted Radical Prostatectomy (RARP) are already established in the literature. However, new robotic platforms have been released recently in the market and their outcomes are still unknown. In this scenario, our objective is to describe our experience implementing the HugoTM RAS robot and report the clinical data of patients who underwent Robotic-assisted Radical Prostatectomy. MATERIAL AND METHODS: We retrospectively analyzed fifteen consecutive patients who underwent RARP with HugoTM RAS System (Medtronic, Minneapolis, USA) from June to October 2021. The patients underwent transperitoneal RARP on lithotomy position, using six trocars (4 robotic trocars and 2 for the assistant). We reported the clinical feasibility and safety of this platform, assessing perioperative data, including complications and early outcomes. Continuous variables were reported as median and interquartile ranges, categorical variables as frequencies and proportions. RESULTS AND LIMITATIONS: All procedures were safe and feasible with no major complications or conversion. Median operative time was 235 minutes (213-271), and median estimated blood loss was 300ml (100-310). Positive surgical margins were reported in 5 patients (33%). The median hospitalization time was 2 days (2-2), and the median time to remove the foley was 7 days (7-7). On the first appointment four weeks after surgery, all patients had undetectable PSA values, and 61% were continent. CONCLUSIONS: We described preliminary results with safe and feasible procedures performed with HugoTM RAS System robotic platform. The surgeries were successfully executed with acceptable perioperative outcomes, without conversions or major complications. However, as this technology is very recent, further studies with a long-term follow-up are awaited to access postoperative functional and oncological outcomes

COVID-19 and slowdown of residents' activity: Feedback from a novel e-learning event and overview of the literature

Objective: To evaluate the impact of an e-learning online event, created for supporting resident's training during the slowdown of surgical and clinical activities caused by COVID-19 pandemic. An overview of PubMed literature depicting the state of the art of urology residency in the COVID-19 era was performed as well, to contextualize the issue.Methods: An online learning event for residents was set up at the beginning of the pandemic; the faculty consisted of experts in urology who provided on-line lectures and videos on surgical anatomy, procedures, updates in guidelines, technology, training. The audience was composed of 30-500 attendees from Italy, USA, India and Belgium. A questionnaire to analyze relevance, satisfaction and popularity of the lessons was mailed to 30 local residents.Results and limitations: Almost all residents defined the web environment suitable to achieve the learning outcomes; the method, the number and the competence of the faculty were appropriate/excellent. Most of the younger residents (81.8%) stated their surgical knowledge would improve after the course; 72.7% declared they would take advantage into routine inpatients clinical activity. Nineteen more expert residents agreed that the course would improve their surgical knowledge and enhance their practical skills; almost all stated that the initiative would change their outpatients and inpatients practice. Overall, 44 articles available in PubMed have addressed the concern of urological learning and training during the pandemic from different standpoints; four of them considered residents' general perception towards web-based learning programs.Conclusions: The paper confirms residents' satisfaction with e-learning methods and, to our knowledge, is the first one focusing on a specific event promptly settled up at the beginning of the outbreak. Web-based educational experience developed during the pandemic may represent the very basis for the implementation of prospective on-site training and overall scientific update of future urologists

Nondetectable Prostate Carcinoma (pT0) after Radical Prostatectomy: A Narrative Review

(1) Background: Following radical prostatectomy (RP), the absence of a demonstrable tumor on the specimen of a previously histologically proven malignancy is known as the pT0 stage. The aim of our present study is to perform a narrative review of current literature in order to determine the frequency and oncological outcomes in patients with pT0 disease. (2) Methods: A narrative review of all available literature was performed. (3) Results: The incidence of pT0 ranges between 0.07% and 1.3%. Predictors of the pT0 stage are only a single biopsy core with low-grade cancer, a cancer length not exceeding 2 mm and a high prostate volume. Biochemical recurrence ranges between 0 and 11%. (4) Conclusions: The absence of malignancy in the RP specimen despite a previous positive biopsy is a rare and unpredictable finding. Although the prognosis is considered to be excellent in most of the cases, a continued close follow-up is warranted

Outcomes of Salvage Robotic-assisted Radical Prostatectomy in the last decade: systematic review and perspectives of referral centers.

ABSTRACT Purpose: Salvage robotic-assisted radical prostatectomy (S-RARP) has gained prominence in recent years for treating patients with cancer recurrence following non-surgical treatments of Prostate Cancer. We conducted a systematic literature review to evaluate the role and outcomes of S-RARP over the past decade. Materials and Methods: A systematic review was conducted, encompassing articles published between January 1st, 2013, and June 1st, 2023, on S-RARP outcomes. Articles were screened according to PRISMA guidelines, resulting in 33 selected studies. Data were extracted, including patient demographics, operative times, complications, functional outcomes, and oncological outcomes. Results: Among 1,630 patients from 33 studies, radiotherapy was the most common primary treatment (42%). Operative times ranged from 110 to 303 minutes, with estimated blood loss between 50 to 745 mL. Intraoperative complications occurred in 0 to 9% of cases, while postoperative complications ranged from 0 to 90% (Clavien 1-5). Continence rates varied (from 0 to 100%), and potency rates ranged from 0 to 66.7%. Positive surgical margins were reported up to 65.6%, and biochemical recurrence ranged from 0 to 57%. Conclusion: Salvage robotic-assisted radical prostatectomy in patients with cancer recurrence after previous prostate cancer treatment is safe and feasible. The literature is based on retrospective studies with inherent limitations describing low rates of intraoperative complications and small blood loss. However, potency and continence rates are largely reduced compared to the primary RARP series, despite the type of the primary treatment. Better-designed studies to assess the long-term outcomes and individually specify each primary therapy impact on the salvage treatment are still needed. Future articles should be more specific and provide more details regarding the previous therapies and S-RARP surgical techniques

A nomogram to predict pathologic T2 stage in candidates to robot-assisted radical prostatectomy with iT3 prostate cancer on preoperative multiparametric MRI: results from a multi-institutional collaboration

: In candidates to robot-assisted radical prostatectomy (RARP) for locally advanced (iT3) prostate cancer on preoperative MRI, the performance of MRI for local staging is demonstrably suboptimal, and currently no prediction tools that might help surgeons in preoperative planning are available. We analyzed data of 685 patients with iT3 prostate cancer (PCa) who received RARP at five participating institutions between 2012 and 2020. Multivariable logistic regression model investigated predictors of pT2 disease among variables available before surgery (i.e: preoperative PSA, biopsy ISUP group, clinical T stage on digital rectal examination-DRE, prostate volume on MRI, PIRADS score of index lesion, seminal vesicles invasion on MRI, location suspicious for T3 disease on MRI). Coefficients from such model were used to build a nomogram to predict organ-confined (i.e. pT2) disease on final pathology. Internal validation was performed using the leave-one-out cross-validation. Median (interquartile range) preoperative PSA was 7.5 (5.2, 11.9) ng/ml, and 280 (41%) and 216 (32%) had biopsy ISUP group 4-5 disease and palpable disease on DRE, respectively. Preoperative MRI was suspicious for iT3 disease on the mid-posterior part of the gland in 485 (71%) men, and 527 (77%) men had a PIRADS 5 lesion. After surgery, a total of 192 (28%) patients had organ-confined disease (i.e. pT2). All variables fitted into the model and were considered to build the nomogram. After internal validation, the AUC was 73% (95% confidence interval: 69%, 77%). Awaiting external validation, we provided data that is relevant to optimize surgical strategy in men diagnosed with iT3 PCa who are scheduled for RARP

Positive Surgical Margins After Anterior Robot-assisted Radical Prostatectomy: Assessing the Learning Curve in a Multi-institutional Collaboration

Background: The learning curve for robot-assisted radical prostatectomy (RARP) remains controversial, with prior studies showing that, in contrast with evidence on open and laparoscopic radical prostatectomy, biochemical recurrence rates of experienced versus inexperienced surgeons did not differ. Objective: To characterize the learning curve for positive surgical margins (PSMs) after RARP. Design, setting, and participants: We analyzed the data of 13 090 patients with prostate cancer undergoing RARP by one of 74 surgeons from ten institutions in Europe and North America between 2003 and 2022. Outcome measurements and statistical analysis: Multivariable models were used to assess the association between surgeon experience at the time of each patient's operation and PSMs after surgery, with adjustment for preoperative prostate-specific antigen level, grade, stage, and year of surgery. Surgeon experience was coded as the number of robotic radical prostatectomies done by the surgeon before the index patient's operation. Results and limitations: Overall, 2838 (22%) men had PSMs on final pathology. After adjusting for case mix, we found a significant, nonlinear association between surgical experience and probability of PSMs after surgery, with a lower risk of PSMs for greater surgeon experience (p < 0.0001). The probabilities of PSMs for a patient treated by a surgeon with ten, 250, 500, and 2000 prior robotic procedures were 26%, 21%, 18%, and 14%, respectively (absolute risk difference between ten and 2000 procedures: 11%; 95% confidence interval: 9%, 14%). Similar results were found after stratifying patients according to extracapsular extension at final pathology. Results were also unaltered after excluding surgeons who had moved between institutions. Conclusions: While we characterized the learning curve for PSMs after RARP, the relative contribution of surgical learning to the achievement of optimal outcomes remains controversial. Future investigations should focus on what experienced surgeons do to avoid positive margins and should explore the relationship between learning, margin rate, and biochemical recurrence. Understanding what margins affect recurrence and whether these margins are trainable or a result of other factors may shed light on where to focus future efforts in surgical education. Patient summary: In patients receiving robotic radical prostatectomy for prostate cancer, we characterized the learning curve for positive margins. The risk of surgical margins decreased progressively with increasing experience, and plateaued around the 500th procedure. Understanding what margins affect recurrence and whether these margins are trainable or a result of other factors has implications for surgeons and patients, and it may shed light on where to focus future efforts in surgical education

The Surgical Learning Curve for Biochemical Recurrence After Robot-assisted Radical Prostatectomy

Background: Improved cancer control with increasing surgical experience-the learning curve-was demonstrated for open and laparoscopic prostatectomy. In a prior single- center study, we found that this might not be the case for robot-assisted radical prosta-tectomy (RARP).Objective: To investigate the relationship between prior experience of a surgeon and biochemical recurrence (BCR) after RARP.Design, setting, and participants: We retrospectively analyzed the data of 8101 patients with prostate cancer treated with RARP by 46 surgeons at nine institutions between 2003 and 2021. Surgical experience was coded as the total number of robotic prostate-ctomies performed by the surgeon before the patient operation. Outcome measurements and statistical analysis: We evaluated the relationship of prior surgeon experience with the probability of BCR adjusting for preoperative prostate-specific antigen, pathologic stage, grade, lymph-node involvement, and year of surgery.Results and limitations: Overall, 1047 patients had BCR. The median follow-up for patients without BCR was 33 mo (interquartile range: 14, 61). After adjusting for case mix, the relationship between surgical experience and the risk of BCR after surgery was not statistically significant (p = 0.2). The 5-yr BCR-free survival rates for a patient treated by a surgeon with prior 10, 250, and 1000 procedures performed were, respec-tively, 82.0%, 82.7%, and 84.8% (absolute difference between 10 and 1000 prior proce-dures: 1.6% [95% confidence interval: 0.4%, 3.3%). Results were robust to a number of sensitivity analyses.Conclusions: These findings suggest that, as opposed to open and laparoscopic radical prostatectomy, surgeons performing RARP achieve adequate cancer control in the early phase of their career. Further research should explore why the learning curve for robotic surgery differs from prior findings for open and laparoscopic radical prostatectomy. We hypothesize that surgical education, including simulation training and the adoption of objective performance metrics, is an important mechanism for flattening the learning curve. Patient summary: We investigated the relationship between biochemical recurrence after robot-assisted radical prostatectomy and surgeon's experience. Surgeons at an early stage of their career had similar outcomes to those of more experienced surgeons, and we hypothesized that surgical education in robotics might be an important determi-nant of such a finding.& COPY; 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved

Low Risk of Postoperative Hernia Following Single-port Robot-assisted Radical Prostatectomy: A Report From the Single-port Advanced Research Consortium (SPARC)

OBJECTIVE: To evaluate the risk of postoperative hernia following different approaches of single-port robot-assisted radical prostatectomy (SP-RARP). METHODS: A retrospective review was performed on patients who underwent SP-RARP between February 2019 and December 2022. Demographic and clinical information was collected from the multi-institutional, prospectively-maintained Single-Port Advanced Research Consortium (SPARC) database. Data were analyzed using IBM Statistical Packaging for Social Sciences (SPSS) version 29.0 with descriptive statistics as presented. RESULTS: A total of 1103 patients were identified, consisting of 244 (22.1%), 712 (64.6%), and 147 (13.3%) cases performed via transperitoneal, extraperitoneal (EP), and transvesical (TV) approaches, respectively. During a median follow-up time of 11 months (interquartile range 5.7-17.1 months), only two cases of incisional hernia were reported. Both cases occurred following transperitoneal SP-RARP with one patient requiring surgical repair. There remains no evidence of postoperative hernia following EP and TV SP-RARP at the completion of our review. CONCLUSION: SP-RARP was associated with low risk for postoperative hernia. The risk was lower following TV and EP SP-RARP where the peritoneum is preserved